Patients Waking Up During Surgery? Have Your Anesthesia Carts Ready

Accidental Awareness

It’s the stuff of nightmares and something many of us have considered at one point in our lives: “What if I were to wake up during surgery?” While uncommon, this phenomenon does happen. It’s referred to as “accidental awareness.” A patient, even under anesthesia, wakes up during the surgical procedure being performed on them. Doctors are unaware it is happening and the patient feels it all.

Warning: Skip this paragraph if you have a weak stomach. During an episode of accidental awareness, the patient comes out of their drug-induced “sleep” to hear and even feel surgeons performing the surgery. They can feel each cut of the scalpel. They can feel the tugging, pulling and removal of parts of their body. They can feel their lungs unable to take a full breath. The worst part is they cannot speak to alert anyone they are, in fact, awake. They suffer in silence, in panic, in pain.

They can feel all of this and hear the surgeons, nurses and anesthesiologist speaking, the sounds of the heart monitor and machines, yet they cannot communicate because components of the administered anesthesia have temporarily paralyzed their ability to move or speak. The brain is awake, but the body is asleep.

These are the sensations survivors of accidental awareness report. As you can imagine, this event can cause significant physical pain, as well as long-lasting psychological damage. A comprehensive study by Anaesthesia of accidental awareness found that your risk for experiencing it is around 0.005 percent, about one in 19,600. In the United States, it is estimated there are more than 21 million surgeries per year that require general anesthesia. That means roughly 1,000 of those patients will, unfortunately, wake up during a surgical procedure. The odds are in your favor, but if you happen to find yourself one of those 1,000, the event could be life-changing.

What Are The Risks?

The study found that in the majority of accidental awareness events occurred either while the patient was being put under anesthesia or when they were being brought out of their anesthesia state. It was rare for a patient to experience accidental awareness during the surgical procedure, thankfully, however, it does happen. Even if accidental awareness occurs pre- or post-op, waking up without being able to communicate or move before the proper time can be scary, nonetheless.

It is interesting to note that we do not all share the same risk factors. In fact, women are more likely than men to experience accidental awareness and young adults have a higher propensity for the phenomenon. Those who are obese also carry a higher risk.

Beyond physical factors, the type of surgery makes a difference. Emergency surgeries carry a higher risk, as well as C-sections. It is believed because these types of surgeries often require less sedation than other surgeries, perhaps the smaller quantities of anesthesia enable some patients to come out of their anesthesia sooner. The anesthesiologist also plays a role. Those with less experience may miscalculate the quantity of medication to give to a patient, thereby increasing their risk for waking up during the procedure.

If a patient does wake up during surgery, they typically report feeling pain and often, the feeling of being asphyxiated. A report from the Royal College and the Association of Anaesthetists of Great Britain and Ireland, studying three million operations, discovered 51 percent of those who report an accidental awareness event said the incident caused them distress and 41 percent suffered long-term psychological damage, including post-traumatic stress disorder (PTSD).

While the type of anesthesia used and the ways they are used do show some correlation, the improper use of muscle relaxants seems to have a greater effect. When patients are unable to move, speak or communicate while they are in the awakened state, it creates internal panic that contributes to the long-term psychological damage.

Can Anesthesia Carts Help?

Some experts believe using nerve stimulators on each patient undergoing surgery can help. Nerve stimulators, placed at various points along the body and connected to a monitor, would give doctors data on the patient’s actual state of paralysis. The anesthesiologist could use this data to maintain the proper levels of muscle relaxants and other medications required to sedate the body during surgery. By giving the patient only the minimum amount of muscle relaxants, the patient would be better able to move if they were feeling pain. If the patient moves during surgery, the anesthesiologist would immediately know the patient is coming out of their anesthesia and could instantly administer more medications to put them into a deeper state.

This is where anesthesia carts come into play. Anesthesiologists need to have all of their equipment, tools, medication and supplies readily available and efficiently organized so they can react quickly to the changing state of their patients. An anesthesia cart is meant to store such items and arrange them so they are at the fingertips of the doctors. The longer it takes the doctor to locate what he or she needs to proactively respond to their patient’s immediate needs, the more likely the patient is to remain in a compromised state.

Anesthesia Carts Offer Additional Benefits to Surgical Centers

We see the benefits of anesthesia carts go beyond patient care. Surgical centers are under pressure to reduce costs and find efficiencies wherever they can. Staffing costs present the highest expenditures, however, making the surgical procedures (from pre-op phone calls to post-op care) more efficient is, perhaps, the lowest hanging fruit. By looking at how a surgical center operates, areas for improvement can likely be found.

In an article by Becker’s ASC Review, one way surgical centers can cut costs is by helping anesthesiologist be more efficient. “The skill level of a provider can really impact the flow of the room, and if they’re doing eight or nine cases in a day and the anesthesia provider is really slow, that could add an hour to the day easily. A provider that can get the patient prepared and under anesthesia more efficiently can be a huge cost-savings.”

Anesthesia carts are a simple way to help anesthesiologist perform their duties efficiently and appropriately. In fact, the FGI Guidelines for operating rooms now recommend an anesthesia cart be part of “the minimum equipment for a surgical procedure,” along with an anesthesia machine, an anesthesia professional chair, intravenous pole or table, case cart/equipment delivery system cart, prep stand, and several other smaller items, such as various waste receptacles.

Features to Look for in an Anesthesia Cart

Anesthesia carts vary in size, function and onboard items, however, they are intended to store everything needed to aid a surgical procedure that requires the administration of anesthesia. Again, the tools must be organized in a way that makes sense for the procedure, thereby requiring the anesthesia cart to be somewhat flexible to the needs of the anesthesiologist and the procedure he or she is performing.

In order to ensure the patient is under the proper levels of anesthesia to prevent accidental awareness and unnecessary pain during every stage of the procedure, the anesthesiologist must have all of his or her supplies at arm’s reach. There should be no reason for a doctor to have to ask a nurse to find an item for him or her, particularly if that item is not already in the anesthesia cart. This takes prior planning on the hospital’s or surgical center’s part. They must communicate with the surgeon and anesthesiologist in order to understand the procedure to take place and what supplies will be required on the anesthesia cart.

Anesthesia carts are typically mobile, making them even more convenient for the anesthesiologist to move to his or her side. Not all surgical rooms are arranged the same, therefore, being able to place the cart in an optimal location is critical for efficiency and patient safety sake.

Further, an anesthesia cart’s mobility enables the cart to be moved from surgical room to surgical room with ease. It can also be moved to the nursing station, supply room or sanitation room with little effort. By easing transport, doctors and nurses save valuable time and energy by not having to locate items throughout the facility.

Because the anesthesia cart may contain items that could be mishandled or cause injury, it should have at least some locking drawers and all four wheels should have locking mechanisms to prevent them from unintentionally rolling during their use. All of the drawers should be easy to open and close with one hand and be made of a non-porous material to prevent the spread of bacteria, germs or viruses. They should be able to be easily cleaned for the same reasons.

What Tools Are Typically Found on Anesthesia Carts?

The type of procedure being performed will vary, therefore, the tools and supplies on the anesthesia carts will range. It is common to find extra IV push medications for the administering and reversal of anesthesia. It may also contain the required tools for respiratory support and resuscitation, such as patient face masks, tubing and endotracheal intubation supplies.

Other items commonly found on an anesthesia cart may be a laryngeal mask airway and tube to keep the patient’s airway open during surgery, an Odom’s indicator to locate epidural space to administer anesthesia, extra surgical gloves and doctor face masks, scalpels, IV tubing, extra saline bags, drip chambers and ports, and other related items.

The location of these and other anesthesia cart items is critical to enforce the most efficient operations. Anesthesiologists must anticipate complications and emergencies, such as accidental awareness, and ensure their anesthesia carts contain the necessary tools and supplies to enable them to rapidly respond.

Beyond the Surgery

Every time a patient undergoes surgery, they are quite literally placing their lives into the hands of many the assume are experts. The surgeon, anesthesiologist, nurses and other doctors who may be present must all work in concert to optimize the patient’s experience and outcome. A single glitch in something as simple as having the right supplies at hand can cause major, even critical effects.

If an unfortunate patient does awake during a surgical procedure, the doctors must understand the patient may require ongoing support to overcome their PTSD. Even if the event does not cause PTSD, few patients are able to resume normal psychological functioning after an accidental awareness event. It is traumatizing on many levels and at the very least, the patient can experience long-term nightmares, poor sleep, and health and surgical anxieties that may prevent them from seeking medical help for urgent issues in the future.

When a patient experiences such an episode, doctors must help them find appropriate counseling and support so they are not left to suffer alone. By taking responsibility for their part in the accidental awareness event, doctors can make a significant impact in how the patient recovers from the incident. They can also use the information gathered from the specific event to sharpen their skills, seek best practices, train support personnel and ensure the proper tools are on their anesthesia carts for every future surgery.

Accidental awareness may not be absolutely preventable, but its proclivity can be greatly reduced. It is up to the doctors and surgical facility to assess the risk factors and take action to lessen that risk on a per-patient basis. Finally, doctors should inform their patients of their own risk factors for experiencing accidental awareness. Although incidents are rare, many patients fear it will happen to them. By discussing the rates of occurrence, their risk factors and the steps the doctor will take to prevent and respond to it if it occurs can put the patient at ease.

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